Basic Information
| Provider Information | |||||||||
| NPI: | 1588081731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDS PATH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 864557 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750864557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146810344 | ||||||||
| FaxNumber: | 2142915692 | ||||||||
| Practice Location | |||||||||
| Address1: | 8720 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750333079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146810344 | ||||||||
| FaxNumber: | 2142915692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOATMAN | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2146810344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.S., B.C.B.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-12040 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 0002BF | 01 | TX | BCBS | OTHER | 12347082668 | 01 | TX | TRICARE | OTHER | 1316338544 | 01 | TX | NPI | OTHER | 1720332117 | 01 | TX | INDIVIDUAL NPI | OTHER | 1851718209 | 01 | TX | NPI | OTHER | 3639503 | 01 | TX | UNITED HEALTH CARE | OTHER |